EDI Reports Documentation

Reports and Response Transactions

Reports and Response Transactions are provided to Trading Partners to enable them to track the transactions that are submitted to NEBLUEconnect.

Each report reflects that different level of review has been completed. First, the transaction file is reviewed and finally in the case of 837 transactions, individual healthcare claims are reviewed.

Only the claims that pass all reviews are submitted to BCBSNE for processing. Rejects can occur at various points during the review process so ALL reports must be reviewed by the Trading Partner to determine status of the submission. The ONLY way a Trading Partner is informed that a rejection has occurred is through one of these reports.

Transmission Reports

These reports reflect the progress of a transaction before it is submitted to BCBSNE for processing.

TA1 Report - Interchange Acknowledgment

The TA1 Report is generated as the result of a review of the data that was transmitted in the ISA segment of the transaction. A report is automatically generated if there is a problem with the transaction and the file will not be processed any further. If the ISA14 segment is a "1", this report is generated whether there is an error or not.

This report is placed in the Trading Partner's mailbox within an hour of the transmission if there is an error or if the appropriate flag is set in the file.

999 Report - Functional Acknowledgment

The 999 is a standard X12 transaction. This process validates that the X12 file meets syntax and structure rules of the ANSI X12 Standard.

This report is placed in the Trading Partner's mailbox within an hour of the transmission.

NEBLUEconnect Claims Confirmation Report

This report is specific to claims processing and is not generated for any other type of healthcare transaction. The Claims Confirmation Report gives the Trading Partner a detailed view of each claim received in a specific file. The Claims Confirmation Report lists errors in syntax and structure compliance with HIPAA Implementation Guides for the 837's and any errors against BCBSNE business rules which are contained in our 837 Companion Document.

This report is placed in the Trading Partner's mailbox within an hour of the transmission.

CHIROPRACTOR "EXPANDED' REPORT (SC)

The Chiropractor "Expanded" Report is the result of editing Nebraska Blue Shield chiropractic claims against a "patterns of treatment" database.

The report is placed in the Trading Partner's mailbox the day after the 837 claim transaction is received.

Professional Claims (837P) (CMS) Also Dental (837D)

  • Individual NPI numbers or Type One MUST always be present to successfully process professional claims. Please populate the individual NPI's in the rendering provider loop of the electronic file (Loop 2310B - NM1 09).
  • If you also have a Group NPI or Type Two, you may populate that number in the Billing provider loop (Loop 2010AA - NM1 09). The individual NPI still needs to be present. (Loop 2310B - NM1 09)
  • If you only have an Individual NPI you can repeat the provider information in the Rendering loop (2310B) into the Billing provider loop (2010AA) or just create a Billing provider loop containing the Individual Type One provider NPI. The Individual or Type One NPI Must appear on all professional claims.

*The Tax ID is still required.

Institutional Claims (837I) (UB04)

  • Type Two NPI numbers MUST be present to successfully process institutional claims. Please populate the Type Two (Group) NPI in the Billing provider Loop (2010AA - NM1 09).
  • Please be sure to use the NPI number that is appropriate for the service(s) on the claim. For example, do not use an acute care NPI on claims billed for your Skilled Nursing Facility, please use the NPI you assigned to your Skilled Nursing Facility.

*The Tax ID is still required.

Standard Response Transactions

In addition to the 999 Functional Acknowledgment described previously, the HIPAA standard response reports supported include the 835 Health Care Claim Payment/Advice, 271 Health Care Eligibility/Benefit Inquiry and Information Response and 277 Health Care Claim Status Response.

The 835 response is placed in the Trading Partner's mailbox the day after the claims are adjudicated by BCBSNE.

The 271 and 277 responses are placed in the Trading Partner's mailbox the day after the transaction is received.

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HEALTH INSURANCE TERMS



Affordable Care act

The Affordable Care Act (ACA), sometimes called Obamacare, is a federal law designed to make health care more affordable, accessible and of higher quality.

COINSURANCE

The percentage of the bill you pay after your deductible has been met.

COPAY

A fixed amount you pay when you get a covered health service.

DEDUCTIBLE

The annual amount you pay for covered health services before your insurance begins to pay.

emergency care services

Any covered services received in a hospital emergency room setting.

health insurance marketplace (exchange)

The government Website (healthcare.gov) where you can purchase health insurance and see if you qualify for a tax credit (subsidy) to help pay premiums and out-of-pocket costs. 

in-network provider

A provider contracted by your insurance company to accept an agreed upon payment for covered services. 

OUT-OF-network provider

A term for providers that aren’t contracting with your insurance company. (Your out-of-pocket costs will tend to be more expensive if you go to an out-of-network provider.)

out-of-pocket

Your expenses for medical care that aren’t reimbursed by insurance, including deductibles, coinsurance and co-payments.

penalty

If you can afford health insurance, but choose not to buy it, you must have a health coverage exemption or pay a tax penalty on your federal income tax return.

premium

The amount you pay to your health insurance company each month. 


Preventive services

Health care services that focus on the prevention of disease and health maintenance.

rehab SERVICES

Services and devices to help you recover if you are injured or have surgery. This includes physical, occupational and speech therapy.

special enrollment period

The time after the Open Enrollment Period when you can still purchase health insurance only if you have a qualifying life event (losing other health coverage, having a baby, getting married, moving).

specialist

A physician who has a majority of his or her practice in fields other than internal or general medicine, obstetrics/gynecology, pediatrics or family practice.

SUBSTANCE ABUSE DISORDER SERVICES

Includes behavioral health treatment, counseling, and psychotherapy.

tax credit

Financial assistance from the government that helps those who are eligible pay for health insurance. Eligibility is generally determined by household income and family size.

Tiered benefit plan

A health care plan featuring multiple levels of benefits based on the network status of a particular provider.